CLAIM FORM OPD - TO BE FILLED IN BY THE INSURED

The issue of this Form is not to be taken as an admission of liability (To be filled in block letters)

DETAILS OF PRIMARY INSURED Section A

UHID No.: 2999203918399301000 Employee ID: 02890B

Company Name: IBM - EMPLOYEE (ESC) Reference No: D300520210510398448

DETAILS OF INSURED PERSON Section B

Policy Holders Name: IBM - EMPLOYEE (ESC)

Insured Person's Name: SUMIT GARG

Gender: Male Female Diagnosis:

Relationship: Self Spouse Child Father Mother Other

Address:

Landmark: City/Town:

District: State:

Telephone: Mobile: 9999401129

Pin
E-Mail:
Code:

DETAILS OF CLAIM AND DOCUMENTS TO BE SUBMITTED: Section C

Duly filled claim form Bills and payment receipts

Consultation papers (It should have qualifications of the treating doctor) OPD (Dental X-ray) report in case of dental treatment
Prescriptions of tests advised Any other documents submitted
Prescriptions of medicines advised All financial documents should be in original. Photocopies will not be accepted
Investigation reports ID proof of the insured

DETAILS OF PRIMARY INSURED?S BANK ACCOUNT: Section E

PAN No: Account No: 01********78

Bank Payable details:

ICICI BANK
Name/Branch: Cheque/DD

IFSC Code: I*********8 * please attach a cancelled cheque pertaining to the same

MICR No: * please attach a cancelled cheque pertaining to the same

Note:
It is agreed that the Policyholder/Claimant will intimate in writing to HDFC Ergo Health. about any change in bank account details.
In an event Insured person bears expenses for treatment, please provide account details of Insured Persons in the above format along with proof of incurring such
expenses.

DETAILS OF BILLS ENCLOSED: Section D

No Bill No. Bill Date Bill Amount Remarks
1 MNM/21-22/00005896 01-May-2021 5400 Investigation & Lab Charges
2 1 05-May-2021 6000 Investigation & Lab Charges
3 00009657 14-May-2021 1100 Investigation & Lab Charges
4 00006538 26-May-2021 1688 Investigation & Lab Charges
5 17809 29-May-2021 448 Investigation & Lab Charges
6 1656 27-Apr-2021 2500 Consultant Charges

DECLARATION BY THE INSURED: Section F

I hereby declare that the information furnished in this claim form is true & correct to the best of my knowledge and belief. If I have made any false or untrue statement,
suppression or concealment of any material fact with respect to questions asked in relation to this claim, my right to claim reimbursement shall be forfeited. I also consent
& authorize TPA / insurance company to seek necessary medical information / documents from any hospital / Medical Practitioner who has attended on the person
against whom this claim is made. I hereby declare that I have included all the bills / receipts for the purpose of this claim & that I will not be making any supplementary
claim, if any.
 Signature of the
Date: Place: insured:

Note:Claim form, cancelled cheque and all financial documents like Consultation bill/ Receipts and any other bills are required in original hard copy to be submitted at
nearest IBM help desk or to be couriered to Medi Assist Bangalore office within 3-4 working days for the final settlement of the claim. Medi Assist Bangalore office
address is given below
MEDI ASSIST INSURANCE TPA PRIVATE LIMITED
4th Floor, Tower D, IBC Knowledge Park,
Bannerghatta Road, Bengaluru 560 029